Examining disparities surrounding lung cancer screening

ALE Spotlight: A longitudinal look at eligible population and low-dose computed tomography screening rates for lung cancer in Maine
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By Mary Dionne, MPH22, Epidemiology-Biostatistics

In the spring of 2022, I began exploring organizations that would allow me to delve into the issue of health equity. Being from a rural state like Maine, I discussed capstone topics that touched upon rural health access and prevention, lung cancer stigma and screening, and the consequences of agricultural pesticides and fertilizers on water supplies. All of these potential projects had the common thread of equity, were with quality, dynamic organizations, and would create an exciting backdrop for my Applied Learning Experience (ALE). However, as I explored the topics further, I became more intrigued by the disparities surrounding lung cancer.

Despite a widespread understanding of what causes lung cancer in the United States with 80-90 percent being associated with cigarette smoking, it is the second most common cancer and accounts for more fatalities than colon, breast, and prostate cancer combined. Despite this high mortality rate, lung cancer research is underfunded due to its lack of public empathy and view as a preventable disease.3 Also, studies have shown that health disparities are present in both smoking and lung cancer screening rates, such as groups with low socioeconomic status, people of color, those on Medicaid, individuals with less than a high school degree, and people who live in rural areas.

From 2014-2016, in those individuals aged 55 or older that were identified as having lung cancer, over 70 percent were in the form of late-stage lung cancer. It has a low survival rate, where on average only 19 percent of individuals with lung cancer live five years after diagnosis. Also, if lung cancer metastasizes and moves to other body areas, the average five-year survival rate decreases from 19 to five percent. Since early detection is key in this high-mortality cancer, it is critical for those who are eligible and at high risk get an LDCT screening, the most effective screening tool to date.

My ALE project examined the trends in lung cancer screening, as well as aimed to obtain information about the role of social determinants of health (SDOH) and to understand better where lung cancer screening education and outreach should be targeted throughout the state of Maine. The organization that I worked with was the Maine Lung Cancer Coalition (MLCC), which falls under Maine Health Institute for Research (MHIR). The MLCC is comprised of researchers, physicians, hospital representatives, and other stakeholders whose goal is to educate through the development and implementation of innovative practices that will increase engagement in preventative measures, screening, and treatment for those at high risk for lung cancer.

The implementation of my ALE project encompassed a variety of activities. I began the process by doing a literature synthesis of lung cancer screening methodologies, the role of the SDOH and shared decision making in lung cancer screening uptake, and the role of stigma in lung cancer. Next, I examined Maine’s 2017-2019 Behavioral Risk Factor Surveillance System (BRFSS) data to select the variables of interest and the method for choosing the eligible lung cancer screening population. Once the lung cancer screening eligible population was gleaned, I used complete case analysis in Stata 17 to perform prevalence ratios, proportions t-tests, and chi-square tests of independence for the outcome and potential predictor variables on each year of the BRFSS data. A secondary analysis of each county’s lung cancer burden and screening rate were accomplished to assist with targeting MLCC educational and advocacy efforts. A third analysis was added during the ALE to inform the MLCC and other stakeholders of the role that shared decision making may play in lung cancer screening uptake.
My ALE experience taught me several things. Doing the county analysis and examining the social determinants of health reminded me that many different metrics can be used to measure diversity. When we hear diversity, the first thing that comes to mind is race/ethnicity or gender identity. However, it is much more than that. Maine has unique characteristics, and its diversity does not encompass one social construct but is shaped by many intersecting factors. Therefore, it is vital to engage stakeholders when doing epidemiological research and learn from them so that one can consider each community's uniqueness instead of only allowing the evidence from the general literature to inform one’s decisions. Also, national data sets may not be the best way to assess salient behavioral and health factors, even if it is the most feasible.

My project afforded me the experience of becoming immersed in both the epidemiological and the biostatistical facets of public health, which was essential for my intellectual and experiential growth. Additionally, I learned to be flexible and patient with the process. Changes to timelines and activities occur, and one must be able to adapt while still focusing on the project's overarching goal. As a practitioner, I realized that I like working collaboratively and the exchange of ideas that goes along with it. Lastly, it became apparent that public health is a great field for a lifelong learner, which I am. The diversity of topics in the field provides the opportunity to continue learning new skills and improving oneself. This capstone experience reaffirmed that this is the right career for me, and I am thankful to Tufts, MLCC, and MHIR for giving me the opportunity.

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